Why would anyone do an emergency medicine residency?

[boomshaketheroom]

I've rotated in settings where I was seeing 25-30 patients a day (if not slightly more) and had dozens and dozens of those complaints. Addressed them myself. Attending came in to give the blessing and patient left satisfied. Please don't equate being a med student to not understanding the complexity of the complaints.
And you make your diagnosis in 1 minute and then spend 15 minutes explaining why antibiotics don't help? lol.

I think being a med student specifically means less understanding of the complexity of complaints.

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[TheComebacKid]

I've rotated in 2 EDs and both let me intubate. My classmate rotated in 3 other EDs and he got to intubate in 2/3. I would agree that a majority of EDs wouldn't let a med student intubate but quite a few do.
Why are they a hard no?? Are they difficult intubations? Risky (ex. upper GI bleeds) where you need the first pass? Residents around who need the exp?

When EM residents aren't around, no reason a student can't intubate. I've gotten a 2nd pass twice (once in the ed, once in the icu) as well.
Especially true if you have a lot of numbers from anesthesia etc. because at that point your airway skills are on par with some em interns.

If there are EM residents, no way in hell is a med student intubating. Sorry. When I was a med student, that concept made perfect sense to me, and I was perfectly content with reading about airway management and deferring the actual intubation to the residents.

They are a hard no because ED intubation is not anesthesia intubation. Virtually every intubation in the ED has some degree of complexity to it. Every ED intubation is a necessity, in a patient who cannot wait longer. All of the ED patients who are getting intubated have some degree of pathology i.e. horrible respiratory failure, head trauma, status epilepticus, horrible body habitus etc. These are not elective intubations for someone undergoing hip replacement surgery. I've had a handful of peri-intubation arrests in residency, and I'm not proud of that feat, and I've worked really hard to understand ways to properly prevent this from happening, but it just goes to show that some of these patients are being intubated under dire circumstances. Med students seem to have this idea that intubation is fairly easy (just put the tube in the hole) from what they can see on video laryngoscopy, but in fact the nuances of airway management are really complex and something that I have still yet to improve on as a senior resident.

From my perspective, crash intubations in the ED are always for the attending to give up. I'm fortunate to train at a place where they always give it up, but usually they are giving it up to someone who has some degree of experience. An anesthesia rotation in medical school, IMO does not suffice.

 

[MedicineZ0Z]

If there are EM residents, no way in hell is a med student intubating. Sorry. When I was a med student, that concept made perfect sense to me, and I was perfectly content with reading about airway management and deferring the actual intubation to the residents.

They are a hard no because ED intubation is not anesthesia intubation. Virtually every intubation in the ED has some degree of complexity to it. Every ED intubation is a necessity, in a patient who cannot wait longer. All of the ED patients who are getting intubated have some degree of pathology i.e. horrible respiratory failure, head trauma, status epilepticus, horrible body habitus etc. These are not elective intubations for someone undergoing hip replacement surgery. I've had a handful of peri-intubation arrests in residency, and I'm not proud of that feat, and I've worked really hard to understand ways to properly prevent this from happening, but it just goes to show that some of these patients are being intubated under dire circumstances. Med students seem to have this idea that intubation is fairly easy (just put the tube in the hole) from what they can see on video laryngoscopy, but in fact the nuances of airway management are really complex and something that I have still yet to improve on as a senior resident.

From my perspective, crash intubations in the ED are always for the attending to give up. I'm fortunate to train at a place where they always give it up, but usually they are giving it up to someone who has some degree of experience. An anesthesia rotation in medical school, IMO does not suffice.

There's a very lengthy thread on here with anonymous reviews of EM student rotations. A looott of them allowed visiting students to intubate, more than once. I already mentioned I got a 2nd pass after failing the first attempt in the ED, and that is with the senior resident supervising.

If the resident is willing to give it up, then what's wrong with a student getting an attempt? And if there are no EM residents, the student should absolutely get the first pass unless it's a difficult airway/risky etc. I mean why shouldn't they? You learn by doing.

And look, I realize the culture among residents/attendings on here and in many places is that med students are idiots and don't know anything. It's way easier to just avoid teaching them if you have that attitude.

 

[MedicineZ0Z]

I think being a med student specifically means less understanding of the complexity of complaints.

So why do we allow midlevels with even less understanding see these so called less complex patients then?

 

[RNtoMD87]

So why do we allow midlevels with even less understanding see these so called less complex patients then?

One point id like to make is that knowledge doesn’t always beat experience. Some NPs/PAs have 30 years practice experience. Would you trust a med student over them?

 

[MedicineZ0Z]

One point id like to make is that knowledge doesn’t always beat experience. Some NPs/PAs have 30 years practice experience. Would you trust a med student over them?

I wouldn't trust any med student or any midlevel. Most midlevels don't have 30 years exp and on 2 rotations I got taught false info by 2 different supposedly highly experienced midlevels. We naturally love to equate experience to quality when real life isn't like that. Plenty of older highly experienced docs out there who suck.

A more realistic day to day comparison by the numbers of the workforce is to a midlevel with a year or two of experience.

 

[RNtoMD87]

I just judge people individually. I know a lot of IDIOT doctors I work with, that I wouldn't go to for anything, as well as idiot CNAs (that wipe patients faces with bleach), idiot RNs (Mostly floor, clinic, or nursing home- I'm always amazed when I visit my grandma in the nursing home and realize how little the RNs there know...), etc.


But I do know some kick ass midlevels that I would see unless it was something life threatening.

We have ATTENDINGS at my hospital (mostly HMS) that act like they don't know what to do and are expecting us RNs to guide them. I had one a month or so back that we called about a patient decompensating, and he just stared at the patient, seemingly lost. And myself and a NEW nurse were like, "Do you think maybe we can do x,y,z etc" and he was basically doing what we asked him to as we asked. This is AFTER the new nurse called him saying "Hey she is in afib with RVR rate around 150, gets up to 170 at times" and he said "Okay keep monitoring her" and didn't give him an order for any PRNS, and I called him back and said "we need some metoprolol or Cardizem push, and you need to come look at this patient"

The patient ended up going to the unit an hour or so later.

Hospital medicine seems to have the greatest spread of physician skill. We have amazing ones and I love to pick their brain, and some that seem like med students. I don't understand it.

I looked up this doc and he graduated from "Medical University of the Americas" in 2013, so he is fairly new but still.

Another thing to note, I trust various professions in regard to their skill. I expect an NP to be able to keep someone alive, but I don’t expect them to understand advanced medical pathology or pharmacology. I wouldn’t trust them to manage a disease long term, or make precise decisions though.

 

[MedicineZ0Z]

I just judge people individually. I know a lot of IDIOT doctors I work with, that I wouldn't go to for anything, as well as idiot CNAs (that wipe patients faces with bleach), idiot RNs (Mostly floor, clinic, or nursing home- I'm always amazed when I visit my grandma in the nursing home and realize how little the RNs there know...), etc.


But I do know some kick ass midlevels that I would see unless it was something life threatening.

We have ATTENDINGS at my hospital (mostly HMS) that act like they don't know what to do and are expecting us RNs to guide them. I had one a month or so back that we called about a patient decompensating, and he just stared at the patient, seemingly lost. And myself and a NEW nurse were like, "Do you think maybe we can do x,y,z etc" and he was basically doing what we asked him to as we asked. This is AFTER the new nurse called him saying "Hey she is in afib with RVR rate around 150, gets up to 170 at times" and he said "Okay keep monitoring her" and didn't give him an order for any PRNS, and I called him back and said "we need some metoprolol or Cardizem push, and you need to come look at this patient"

The patient ended up going to the unit an hour or so later.

Hospital medicine seems to have the greatest spread of physician skill. We have amazing ones and I love to pick their brain, and some that seem like med students. I don't understand it.

I looked up this doc and he graduated from "Medical University of the Americas" in 2013, so he is fairly new but still.

Sometimes it's just careless and laziness.

 

[RNtoMD87]

I mean I figure it was laziness at first, but he literally came in and just stood infront of the patient and asked them "Oh you don't feel so well huh?....and made small talk and just honestly looked like he didn't know what to do. I said "Would you like to listen to her?" and so he said "yes, yes... that's good idea let me listen" and so on, but I was astounded. I have never seen another doctor act like this. This nurse that had been out of orientation for maybe a month looked at me wide eyed basically saying "Seriously?"

 

[8741empls]

If there are EM residents, no way in hell is a med student intubating. Sorry. When I was a med student, that concept made perfect sense to me, and I was perfectly content with reading about airway management and deferring the actual intubation to the residents.

They are a hard no because ED intubation is not anesthesia intubation. Virtually every intubation in the ED has some degree of complexity to it. Every ED intubation is a necessity, in a patient who cannot wait longer. All of the ED patients who are getting intubated have some degree of pathology i.e. horrible respiratory failure, head trauma, status epilepticus, horrible body habitus etc. These are not elective intubations for someone undergoing hip replacement surgery. I've had a handful of peri-intubation arrests in residency, and I'm not proud of that feat, and I've worked really hard to understand ways to properly prevent this from happening, but it just goes to show that some of these patients are being intubated under dire circumstances. Med students seem to have this idea that intubation is fairly easy (just put the tube in the hole) from what they can see on video laryngoscopy, but in fact the nuances of airway management are really complex and something that I have still yet to improve on as a senior resident.

From my perspective, crash intubations in the ED are always for the attending to give up. I'm fortunate to train at a place where they always give it up, but usually they are giving it up to someone who has some degree of experience. An anesthesia rotation in medical school, IMO does not suffice.

I agree with a lot of what you said. I think in general students can fumble through a lot of procedures lacking real insight into some of the more nuanced aspects of what is going on in the room, yet because they have done a few they feel competent and entitled to the chance to do more (Dunning-Kruger at its finest). That being said, I tubed patients on 2/3 of my Sub-Is with residents in the room, and have had a total of about 15 emergent intubations in ED and ICU settings. I don’t think what you are saying is wrong, just that in my experience it might not be the standard.

 

[MedicineZ0Z]

I agree with a lot of what you said. I think in general students can fumble through a lot of procedures lacking real insight into some of the more nuanced aspects of what is going on in the room, yet because they have done a few they feel competent and entitled to the chance to do more (Dunning-Kruger at its finest). That being said, I tubed patients on 2/3 of my Sub-Is with residents in the room, and have had a total of about 15 emergent intubations in ED and ICU settings. I don’t think what you are saying is wrong, just that in my experience it might not be the standard.

And how do you learn the details then & improve?

 

[SpacemanSpifff]

And how do you learn the details then & improve?

You go to residency.

 

[MedicineZ0Z]

You go to residency.

Oh okay so sounds like you end up practicing more. Who would have thought students need to practice more.

 

[boomshaketheroom]

So why do we allow midlevels with even less understanding see these so called less complex patients then?

The post you wrote that I was responding to wasn’t about midlevels.

 

[thegenius]

Hospital medicine seems to have the greatest spread of physician skill. We have amazing ones and I love to pick their brain, and some that seem like med students. I don't understand it.

I think hospital medicine is the lowest of all medical jobs out there. What a terrible job...they are never happy, overworked, always calling consults, and always responding to meaningless pages every 5 minutes.

"Doctor, the blood pressure is 155/75. Please advise."

"Doctor, the fingerstick blood sugar is 165, should I still give insulin he has been normally taking for 35 years?"

 

[RNtoMD87]

I think hospital medicine is the lowest of all medical jobs out there. What a terrible job...they are never happy, overworked, always calling consults, and always responding to meaningless pages every 5 minutes.

"Doctor, the blood pressure is 155/75. Please advise."

"Doctor, the fingerstick blood sugar is 165, should I still give insulin he has been normally taking for 35 years?"

But when you’re paged because a patient on step down is rapidly decomoensating and needs to be transferred to the unit, and REALIZE that, you can’t just freeze up and stand there, and ask the patient “what you think we should do?”

But I do have to empathize with that, I was talking to a RT last night who was pissed because some medsurg nurse was giving her attitude for not wanting to give a breathing treatment to a patient who had fluid filled lungs. And said “well I’ve done all I can do!” Yet had not even called the MD to stop continuous fluids or to get a diuretic.

Oh and I’m on code team and two days ago we responded to a medsurg code, and it was all the way across the hospital. 5 mins into code, no one had even been recording. “When was last pulse check?” “I don’t f’ing know. I just walked in the room. What was it?”

 

[8741empls]

And how do you learn the details then & improve?

No one is making the argument that experience doesn’t lead to procedural competence. And I’m not saying I don’t enjoy doing procedures or appreciate the experiences I have been given, and of course I get better by doing them. But I also understand when a resident chooses to keep a high risk procedure for themselves for whatever reason they choose.
I think that as students we are often set up for success (by patient selection, help with setup, getting tips throughout the procedure, and having small things done in the background we don’t always realize) and that can give us a false sense of competency early on. For instance I have never missed an intubation, haven’t missed a central line (though I had one be tough a little while ago), or missed an LP. Is this because i’m good at procedures? I don’t think so. Procedures come a little more naturally to me than some of my classmates but I think the real explanation is that I have been set up for success by my attendings and residents. I don’t know, that’s just my $.02.

 

[MedicineZ0Z]

No one is making the argument that experience doesn’t lead to procedural competence. And I’m not saying I don’t enjoy doing procedures or appreciate the experiences I have been given, and of course I get better by doing them. But I also understand when a resident chooses to keep a high risk procedure for themselves for whatever reason they choose.
I think that as students we are often set up for success (by patient selection, help with setup, getting tips throughout the procedure, and having small things done in the background we don’t always realize) and that can give us a false sense of competency early on. For instance I have never missed an intubation, haven’t missed a central line (though I had one be tough a little while ago), or missed an LP. Is this because i’m good at procedures? I don’t think so. Procedures come a little more naturally to me than some of my classmates but I think the real explanation is that I have been set up for success by my attendings and residents. I don’t know, that’s just my $.02.

And I've had the complete opposite experience. Had minimal supervision (which is not good), been handed the blade on a difficult airway and told to go at it in the icu at 2am, gotten a yes to an LP on a bigger person etc.
No one has set me up for success. The best I've gotten is step by step instruction and that's how you learn - being instructed as you physically do it.

 

[Old_Mil]

ACEP may be one of the most anti-physician professional societies in medicine. When they aren't promoting midlevels, they are empowering CMGs and the corporate practice of medicine.

Which is why I am not - and will not be - a member.

Joined AAEM the day I graduated and let my ACEP membership lapse. Never regretted that decision.

 

[Nedsson]

But when you’re paged because a patient on step down is rapidly decomoensating and needs to be transferred to the unit, and REALIZE that, you can’t just freeze up and stand there, and ask the patient “what you think we should do?”

But I do have to empathize with that, I was talking to a RT last night who was pissed because some medsurg nurse was giving her attitude for not wanting to give a breathing treatment to a patient who had fluid filled lungs. And said “well I’ve done all I can do!” Yet had not even called the MD to stop continuous fluids or to get a diuretic.

Oh and I’m on code team and two days ago we responded to a medsurg code, and it was all the way across the hospital. 5 mins into code, no one had even been recording. “When was last pulse check?” “I don’t f’ing know. I just walked in the room. What was it?”

Word. I was on the rapid response/ code team for a few years and floor codes...were nuts. You somehow always had too many people in the space without half of the appropriate steps being taken. It was rough, but I definitely learned a lot from the job...

 

[Indebt4Life]

Bump

 

[boomshaketheroom]

Bump

 

[Indebt4Life]

Because this post is not about doom and gloom. It's more about the medical community being aware of what is happening to medicine. We need to come together and put an end to this. We need to take back medicine.